Brighton and Hove - SPMHS - Referral Form

Information for Referrer:

Routine response time: 20 working days of receipt of referral. Priority referrals: 5 working days.

We welcome discussion of referrals and requests for advice. Please contact SPMHS on 0300 304 0097, who can put you in touch with a practitioner in your area.

Women with mild to moderate symptoms of depression or anxiety (who are managing daily life and do not have areas of high risk) should access support in the first instance through their own GP and/or primary care psychology services:

(Wellbeing Service, referral by GP/health professional or self-referral online at www.hereweare.org.uk.)

Website: https://www.sussexpartnership.nhs.uk/perinatal

Prescribing guidelines can be accessed here: https://tinyurl.com/perinatalprescribing

To send referrals:
Specialist Perinatal Mental Health Service,
East Brighton Community Mental Health Centre
Brighton General Hospital
Elm Grove
Brighton
BN2 3EW

Mainline Telephone Number: 0300 304 0097
Mobile: 07808 632004
Referrals email: spnt.perinatalreferrals@nhs.net

Disclaimer: Please be aware that sending by email from iCloud, Gmail, Hotmail, Live, Yahoo or other private email accounts to NHS.net is not secure. If you would prefer to send the referral form via post please send it to the above address.

Crisis Information:

Same day assessment in crisis is directly through:

MHRRS: 0300 304 0078

PLEASE ENSURE ALL RELEVANT BOXES HAVE BEEN COMPLETED AS GAPS MAY MEAN DELAYS IN ASSESSMENT.

Brighton and Hove - SPMHS - Referral Form

Referral Details:

Referrer Name:*

Referrer Role:*

Location:*

Contact Number:*

Email Address:*

Reply To Email Address (If Different):

Please confirm your email address:

Please choose ONE of the referral criteria for assessment by the perinatal team:*

Prescribed mood stabilising or antipsychotic medication and requesting preconception advice.

Primary tocophobia (fear of childbirth not linked to previous traumatic birth)

Past history of severe mental illness (e.g. bipolar, schizophrenia or severe depression)

Current symptoms of severe mental illness [e.g. bipolar, schizophrenia or severe depression] and/or not responding fully to treatment in the community and/or areas of high risk (please circle any which apply)

Personal / family history (please circle which) of postnatal psychosis or severe postnatal depression (e.g. requiring admission or secondary care)

Neonatal loss/stillbirth (24wks to 28 days after birth)

Has patient given consent for the referral?*

Yes

If not, consider anonymised discussion with a practitioner for advice

Is the Patient:*

Preconception

Antenatal

Postnatal

Being referred for neonatal loss/stillbirth pathway (24wks to 28 days after birth)

Expected Delivery Date: Day

Expected Delivery Date: Month

Expected Delivery Date: Year

Where are they expecting to deliver:

Where did they deliver:

Actual Delivery Date: Day

Actual Delivery Date: Month

Actual Delivery Date: Year

Name of Child:

Date of Delivery: Day

Date of Delivery: Month

Date of Delivery: Year

Patient Demographics

Patient Name:*

Date of Birth: Day*

Date of Birth: Month*

Date of Birth: Year*

NHS Number:*

Ethnicity:*

Address:*

Postcode:*

Email Address:

Home Tel:

Mobile Tel:

Consent to leave voicemail:*

Yes

Consent for text messages:*

Yes

Any Other Children:*

Access needs including disability/interpreter services:*

Is the patient an ex-member of the British Armed Forces or dependent on such a person?*

Yes

Professionals Involved

GP Name:

GP Surgery:

Midwife Name:

Midwife Base:

Health Visitor:

Childrens Centre:

Social Worker:

Hub:

Reason for Referral:

Reason for Referral?*

Is there a known diagnosis/historical mental illness?*

Is the patient open to a mental health team?*

Risk?*

Safeguarding:*

THINK FAMILY: Any safeguarding concerns?

Current medication:*

Relevant medical/obstetric history:*

Any other specialist teams involved:*

Terms & Conditions:

On receipt of the referral it will be allocated to the appropriate locality. Please click here for more information. If you would like to discuss your referral directly with the teams please call;

East Sussex

0300 304 0212

Brighton & Hove

0300 304 0097

North West Sussex

0300 304 0213

Coastal West Sussex

0300 304 0214

You may also email us at spnt.perinatalreferrals@nhs.net

For more information on how information is used, please see our privacy policy.

I have read and agree with the above terms and conditions.*

Same day assessment in crisis is directly through:
MHRRS: 0300 304 0078